MEDICARE: IRC-SCIONHEALTH SELMA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

General Provider Information

NPI Number	:	1568145985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IRC-SCIONHEALTH SELMA LLC

Provider Business Mailing Address
First Line	:	1360 E HIGHLAND AVE
Second Line	:
City	:	SELMA
State	:	AL
Zip	:	36703-3210
Country	:	US
Telephone Number	:	334-876-0076
Fax Number	:	334-375-4049

Provider Business Practice Location Address
First Line	:	1360 E HIGHLAND AVE
Second Line	:
City	:	SELMA
State	:	AL
Zip	:	36703-3210
Country	:	US
Telephone Number	:	334-876-0076
Fax Number	:	334-375-4049

Authorized Official
Title or Position	:	CHIEF NURSING OFFICER
Name	:	MRS. SARA ANNE BRADY
Credential	:
Telephone Number	:	208-371-7878

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	10/13/2023

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